Wednesday, June 01, 2016

Among 375,000 Louisianans newly eligible for Medicaid: 75,000+ Marketplace enrollees

[see updates at bottom and followup re immediate Medicaid enrollments]

Congratulations to Louisiana for kicking off enrollment in Medicaid under its newly enacted ACA Medicaid expansion today. Enrollment begins today and is effective July 1.

The state estimates that 375,000 residents are newly eligible for Medicaid under the program. According to HHS, the state will be the first in the nation to use food stamp (SNAP) data to determine eligibility and enroll people in Medicaid. The Medicaid program has a dedicated website, Healthy Louisiana, that makes online enrollment at least look easy. On the phone, though, I got stuck in impenetrable feedback.loops calling the number there and on the state Dept. of Health & Hospitals website trying to get a live person (there is no media information number listed on either site). I suspect that outgoing GOP governor Bobby Jindal's massive cuts to government agencies has something to do with that.

One subset of newly eligible potential Medicaid enrollees that causes some inevitable disruption in states that belatedly accept the ACA Medicaid expansion is people currently enrolled in ACA marketplace plans whose income now qualifies them for Medicaid.

Under the ACA expansion (rendered optional to states by the Supreme Court in 2012), all residents under age 65 with incomes up to 138% of the Federal Poverty Level (FPL) are eligible for Medicaid, unless barred by immigration status. In states that refused the expansion -- e.g., Louisiana until July 1 -- residents with incomes in the 100-138% FPL range are eligible to buy subsidized private plans in the ACA marketplace. When a state expands Medicaid, marketplace enrollees in that income range become eligible for it -- and at least nominally ineligible for the private plans they were enrolled in to that point.

In Louisiana, as in many poor, "red" states that refused the expansion, a high percentage of enrollees in ACA marketplace plans are in range for Medicaid eligibility. In Louisiana, according to HHS enrollment data, as of the end of open enrollment this year, 46%* of marketplace enrollees, or about 97,600, had incomes in the 100-150% FPL range. While HHS does not break out those in the Medicaid eligibility range, 100-138% FPL, indirect evidence suggests that somewhere between two thirds and three quarters of those 97,600 are now eligible for Medicaid (about 10-15% probably also failed to pay their premiums or have since disenrolled from private plans, but that doesn't affect their Medicaid eligibility).[UPDATE, 6/28/18: Some time after this post was written, HHS broke out enrollment at 100-138% FPL, and we learned that about 85% of enrollees in the 100-150% FPL bracket in nonexpansion states were in the 100-138% FPL band. Marketplace enrollees who became eligible for Medicaid in 2016 thus probably numbered over 75,000.]

Louisiana's ACA private plan marketplace thus stands to lose about one third of its enrollees. Most of them will probably find themselves better off under Medicaid, as focus group data from the Kaiser Family Foundation indicates. That's true even of the probable 85% or so of enrollees in this income range who bought silver plans and so accessed ACA Cost Sharing Reduction (CSR) subsidies. For buyers in the 100-138% FPL income range, a benchmark silver plan costs 2% of income, whereas Medicaid will have no premium. While the CSR-enhanced private plans are designed to cover 94% of the average user's medical expenses, out-of-pocket expenses under Medicaid are even lower, if they exist at all (I am seeking info on LA Medicaid cost-sharing, if any).

Of the perhaps 65-74,000 current Louisiana private plan enrollees now eligible for Medicaid, those who stand to gain the most are the roughly 15%** who chose to enroll in cheaper bronze plans. In New Orleans and Baton Rouge, bronze plans have deductibles ranging from $4,500 to $6750 for a single person and generally offer no services exempt from the deductible, excepting the ACA's mandatory free preventive care.

Transitions for private plan enrollees into Medicaid after belated expansions can be rocky and take some time. I don't know whether the state (or HHS)is doing targeted outreach to private plan enrollees whose incomes likely qualify them for Medicaid. I will update if I find out.

UPDATE, 6/2: Charles Gaba covers much the same ground -- and, folding in normal marketplace attrition, concludes that half of Louisiana's private plan enrollees will drop off the rolls. Charles also notes that Gov. Edwards announced yesterday that 175,000 people -- almost half the estimated total of those newly eligible for Medicaid -- are already enrolled, "because of advance work" [Update - these are apparently mostly transfers from existing limited-Medicaid programs - more here].  Charles also links to a prior post of his discussing our somewhat different estimates of the proportion of enrollees in HHS's 100-150% FPL range who are likely to be Medicaid-eligible (i.e., under 139% FPL). The proportion probably varies from state to state, but his more generous assumptions may be closer to the truth, especially in a poor state like Louisiana.

* HHS reports that 48% of LA enrollees for whom income data is known are in the 100-150% FPL range. Income is unknown for 5% of enrollees in the state. I'm assuming that those enrollees have incomes beyond subsidy range.

** Overall in the state, 75% of those who were eligible for CSR bought silver plans and obtained the benefit. Eligibility for CSR extends  from 0% to 250% FPL. Within that range, generally, the lower the income the higher the takeup. 85% for those in the 100-138% FPL range is a guestimate. As for the 3% under 100% FPL, they should mostly be legally present noncitizens who have not been in the country long enough to qualify for Medicaid. Such residents are eligible for private plan subsidies from 0% FPL on up.

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